<p class="bar"><img src="/images/inquiry/hp/form/img_bar_01.jpg" alt="お客様情報の入力" width="720" height="32" /></p>

<form name="akb201207" method="post" action="" id="input_form">
<!-- inqHouseForm -->
<table id="inqHouseForm">
	<tr>
		<th>対象者&nbsp;<span class="attTxt">[必須]</span></th>
		<td>
			<p>
				<select name="Target" id="Target" class="required">
					<option value="" {if $Target == "" }selected {/if}>選択して下さい</option>
					<option value="01" {if $Target == "01" }selected {/if}>家族</option>
					<option value="02" {if $Target == "02" }selected {/if}>友達</option>
					<option value="03" {if $Target == "03" }selected {/if}>同僚</option>
					<option value="04" {if $Target == "04" }selected {/if}>先輩</option>
					<option value="05" {if $Target == "05" }selected {/if}>後輩</option>
					<option value="99" {if $Target == "99" }selected {/if}>その他</option>
				</select>
			</p>
			<p class="errTxt" htmlfor="Target" generated="true"></p>
		</td>
	</tr>
	<tr>
		<th>応援メッセージ&nbsp;<span class="attTxt">[必須]</span><br/><span class="attTxt">(800文字まで)</span></th>
		<td>
			<p><textarea name="Message" id="Message" maxlength="800" cols="60" rows="5" class="normalInput required">{$Message}</textarea></p>
			<p class="errTxt" htmlfor="Message" generated="true"></p>
		</td>
	</tr>
	<tr>
		<th>お名前(ニックネーム可)&nbsp;<span class="attTxt">[必須]</span><br/><span class="attTxt">(全角)</span></th>
		<td>
			<p><input type="text" value="{$Name}" name="Name" id="Name" class="inputBox01 required zenkaku" maxlength="30" style="IME-MODE: active;" /></p>
			<p class="errTxt" htmlfor="Name" generated="true"></p>
			<p style="font-size: 90%; color: #f66;">※アパマン48キャンペーンページ内で公開されます。</p>
		</td>
	</tr>
	<tr>
		<th>メールアドレス&nbsp;<span class="attTxt">[必須]</span><br/><span class="attTxt">(半角英数値)</span></th>
		<td>
			<p><input type="text" name="Mail" value="{$Mail}" id="Mail" maxlength="50" class="inputBox02 required email alphanum" style="IME-MODE: disabled;" /></p>
			<p class="errTxt" htmlfor="Mail" generated="true"></p>
			<p style="font-size: 90%; color: #f66;">※携帯電話の場合は「apamanshop.co.jp」「apamanshop-fc.com」を受け取る設定にしてください。</p>
		</td>
	</tr>
	<tr>
		<th>電話番号&nbsp;<span class="attTxt">[必須]</span><br/><span class="attTxt">(半角数値)</span></th>
		<td>
			<p>
			<input type="text" name="Tel1" value="{$Tel1}" id="Tel1" maxlength="4" class="inputBox03 required number" style="IME-MODE: disabled;" />
			&nbsp;-&nbsp;
			<input type="text" name="Tel2" value="{$Tel2}" id="Tel2" maxlength="4" class="inputBox03 required number" style="IME-MODE: disabled;" />
			&nbsp;-&nbsp;
			<input type="text" name="Tel3" value="{$Tel3}" id="Tel3" maxlength="4" class="inputBox03 required number" style="IME-MODE: disabled;" />
			</p>
			<p class="errTxt" htmlfor="Tel" generated="true"></p>
		</td>
	</tr>
	<tr>
		<th>性別&nbsp;</th>
		<td>
			<p><input type="radio" name="Sex" id="Sex0" value="0" {if $Sex == 0 }checked {/if}/><label for="Sex0">男性</label>&nbsp;&nbsp;
			<input type="radio" name="Sex" id="Sex1" value="1" {if $Sex == 1 }checked {/if}/><label for="Sex1">女性</label></p>
		</td>
	</tr>
	<tr>
		<th>住所&nbsp;</th>
		<td>
			<p>〒&nbsp;
				<input type="text" name="Zip1" value="{$Zip1}" id="Zip1" maxlength="3" class="inputBox03 number" style="IME-MODE: disabled; background: #fff;" />
				&nbsp;-&nbsp;
				<input type="text" name="Zip2" value="{$Zip2}" id="Zip2" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled; background: #fff;" />
			</p>
			<p><span style="line-height:40px;">都道府県&nbsp;</span>
				<select name="PrefCd" id="PrefCd">
					<option value="00" {if $PrefCd == "00" }selected {/if}>選択して下さい</option>
					<option value="01" {if $PrefCd == "01" }selected {/if}>北海道</option>
					<option value="02" {if $PrefCd == "02" }selected {/if}>青森県</option>
					<option value="03" {if $PrefCd == "03" }selected {/if}>岩手県</option>
					<option value="04" {if $PrefCd == "04" }selected {/if}>宮城県</option>
					<option value="05" {if $PrefCd == "05" }selected {/if}>秋田県</option>
					<option value="06" {if $PrefCd == "06" }selected {/if}>山形県</option>
					<option value="07" {if $PrefCd == "07" }selected {/if}>福島県</option>
					<option value="08" {if $PrefCd == "08" }selected {/if}>茨城県</option>
					<option value="09" {if $PrefCd == "09" }selected {/if}>栃木県</option>

					<option value="10" {if $PrefCd == "10" }selected {/if}>群馬県</option>
					<option value="11" {if $PrefCd == "11" }selected {/if}>埼玉県</option>
					<option value="12" {if $PrefCd == "12" }selected {/if}>千葉県</option>
					<option value="13" {if $PrefCd == "13" }selected {/if}>東京都</option>
					<option value="14" {if $PrefCd == "14" }selected {/if}>神奈川県</option>
					<option value="15" {if $PrefCd == "15" }selected {/if}>新潟県</option>
					<option value="16" {if $PrefCd == "16" }selected {/if}>富山県</option>
					<option value="17" {if $PrefCd == "17" }selected {/if}>石川県</option>
					<option value="18" {if $PrefCd == "18" }selected {/if}>福井県</option>
					<option value="19" {if $PrefCd == "19" }selected {/if}>山梨県</option>

					<option value="20" {if $PrefCd == "20" }selected {/if}>長野県</option>
					<option value="21" {if $PrefCd == "21" }selected {/if}>岐阜県</option>
					<option value="22" {if $PrefCd == "22" }selected {/if}>静岡県</option>
					<option value="23" {if $PrefCd == "23" }selected {/if}>愛知県</option>
					<option value="24" {if $PrefCd == "24" }selected {/if}>三重県</option>
					<option value="25" {if $PrefCd == "25" }selected {/if}>滋賀県</option>
					<option value="26" {if $PrefCd == "26" }selected {/if}>京都府</option>
					<option value="27" {if $PrefCd == "27" }selected {/if}>大阪府</option>
					<option value="28" {if $PrefCd == "28" }selected {/if}>兵庫県</option>
					<option value="29" {if $PrefCd == "29" }selected {/if}>奈良県</option>

					<option value="30" {if $PrefCd == "30" }selected {/if}>和歌山県</option>
					<option value="31" {if $PrefCd == "31" }selected {/if}>鳥取県</option>
					<option value="32" {if $PrefCd == "32" }selected {/if}>島根県</option>
					<option value="33" {if $PrefCd == "33" }selected {/if}>岡山県</option>
					<option value="34" {if $PrefCd == "34" }selected {/if}>広島県</option>
					<option value="35" {if $PrefCd == "35" }selected {/if}>山口県</option>
					<option value="36" {if $PrefCd == "36" }selected {/if}>徳島県</option>
					<option value="37" {if $PrefCd == "37" }selected {/if}>香川県</option>
					<option value="38" {if $PrefCd == "38" }selected {/if}>愛媛県</option>
					<option value="39" {if $PrefCd == "39" }selected {/if}>高知県</option>

					<option value="40" {if $PrefCd == "40" }selected {/if}>福岡県</option>
					<option value="41" {if $PrefCd == "41" }selected {/if}>佐賀県</option>
					<option value="42" {if $PrefCd == "42" }selected {/if}>長崎県</option>
					<option value="43" {if $PrefCd == "43" }selected {/if}>熊本県</option>
					<option value="44" {if $PrefCd == "44" }selected {/if}>大分県</option>
					<option value="45" {if $PrefCd == "45" }selected {/if}>宮崎県</option>
					<option value="46" {if $PrefCd == "46" }selected {/if}>鹿児島県</option>
					<option value="47" {if $PrefCd == "47" }selected {/if}>沖縄県</option>
				</select>
			</p>
			<p><input type="text" name="Address" value="{$Address}" id="Address" maxlength="100" size="80" class="normalInput" style="IME-MODE: active; border: 1px solid #ccc;" /></p>
			<p class="errTxt" htmlfor="Address" generated="true"></p>
		</td>
	</tr>
</table>
<!-- /inqHouseForm -->

{*
<p class="bar"></p>
<p class="read">
<ul>
	<li style="color: #f33;"><strong>応募期限</strong>：2012年7月31日（火）まで。抽選で10名様にプレゼント！</li>
	<li>※グッズ内容は未定です。決定次第、本ページ上でお知らせいたします。</li>
</ul>
</p>
*}

<p id="privacyTxt">▼必ずお読みください。</p>
<div id="privacyTitle">
	<p class="txt">キャンペーン規約</p>
	<p class="link"><a href="{$baseurl}campaign/1206_akb48/kiyaku.html" target="_blank">別ウィンドウで見る</a></p>
</div>
<div id="privacyContents">
	<iframe width="100%" scrolling="auto" height="165" frameborder="no" src="/campaign/1206_akb48/kiyaku.html" id="privacy"></iframe>
</div>

<p id="privacyTxt">▼必ずお読みください。</p>
<div id="privacyTitle">
	<p class="txt">個人情報の取り扱いについて</p>
	<p class="link"><a href="http://www.fcapamanshop.com/privacy.html" target="_blank">別ウィンドウで見る</a></p>
</div>
<div id="privacyContents">
	<iframe width="100%" scrolling="auto" height="165" frameborder="no" src="/app/html/inquiry/privacy.html" id="privacy"></iframe>
</div>

<!-- footTable -->
<table class="footTable">
	<tr>
		<td></td>
		<td>SSL暗号化通信を使用していますので、<br />安心して個人情報を送信いただけます。</td>
		<td>
		<p>
			<a href="javascript:void(0);">
			<input name="Submit" type="image" class="rollImg" id="Submit" src="/images/inquiry/hp/form/btn_input_confirm_02.jpg" alt="「個人情報の取り扱いについて」に同意の上入力内容を確認" width="271" height="66" onclick="javascript:entrySubmit(); return false;"  />
			</a>
		</p>
		</td>
	</tr>
</table>
<!-- /footTable -->

</form>
